The Rising Threats To Our Health

Though evidence of a looming global healthcare crisis is plainly visible, few seem to realize the consequences will be catastrophic to individuals, households and national economies.

Here is a list—by no means exhaustive—of major health issues threatening hundreds of millions of people globally.

Air & Water Pollution

Photos such as these provide graphic evidence that air and water pollution are serious health hazards in many developing nations around the world:

Source: Kyodo News

Source: Independent.co.uk

The statistics are equally horrendous: roughly 40% of all deaths in Pakistan result from polluted drinking water, 500 million people in China lack clean drinking water, and in India, 90% of human waste flows untreated into rivers.

Though the winter smog in Chinese cities is infamous, many other Asian nations suffer from equally poor or even worse air quality:

The health consequences of severe air pollution are many, and a rising number of deaths are attributable to air pollution:

Air and water pollution do not stop at borders, and so severe pollution in developing economies has become a health issue in neighboring developed economies as well.

Ageing Populations

As populations age, health costs rise while the working-age population that must support higher healthcare expenses declines, burdening the middle-aged workers who must support the elderly and the young. Caring for a rapidly expanding population of elderly retirees burdens governments and economies as well as households: as income is taxed to pay for care, there is less money available for other programs and investing in future productivity.

We all know why healthcare costs rise as the population of elderly retirees grows: chronic non-communicable diseases go hand in hand with age. The costs of treating these lifestyle/ageing diseases (metabolic syndrome, heart disease, high blood pressure, etc.) soar as the population and incidence of these diseases both rise.

A recent Standard & Poor’s study, Global Aging 2010: An Irreversible Truth, warns that “no other force is likely to shape the future of national economic health, public finances, and policymaking as the irreversible rate at which the world's population is aging... The cost of caring for [the elderly] will profoundly affect growth prospects and dominate public finance policy debates worldwide.” (Source)

Globally, elderly populations are rising even in developing nations.

Smoking

Over 1 billion people smoke cigarettes globally, with some 350 million smokers residing in China. Over one million deaths per year in China are attributed to smoking, but some estimates project this number rising to 3.5 million annually.

This epidemic will overwhelm a global healthcare system that is already struggling to provide care for an aging population.

The consequences of diabetes include higher mortality among those under the age of 60, with major consequences in productivity and time lost to illness:

What is particularly striking is the disconnect between statistics that claim low obesity rates in developing countries such as India and China and soaring rates of diabetes in these same countries:

Meanwhile, other sources have published estimates of overweight/obesity in China that parallel data from developed nations with equivalent rates of diabetes.

Clearly, the factors linked to metabolic syndrome—diets rich in refined foods, sugar, and unhealthy fats, a lack of exercise, etc.—are on the rise in developing nations, regardless of the supposed rate of obesity (generally defined as a body mass index (BMI) of over 30) and being overweight (generally defined as a BMI of over 25).

Competition for Resources

Though few connect global health with the rising human population, common sense suggests that the global competition for resources and the rising costs of providing basics such as clean water and air, and energy and food security, will pressure global health for purely financial reasons: if national incomes are increasingly devoted to expenditures such as military forces, energy and food security, interest due on sovereign debt, etc., relatively fewer resources will be available to fund healthcare for the rising numbers of elderly retirees and the enormous populations suffering from chronic diseases that require constant monitoring and treatment.

Many people look to technology to solve these inter-related problems. Perhaps miraculous advances in biochemistry will solve all these global health crises. But a cautious skepticism is in order, for all sorts of wondrous but costly technologies that work in the lab and small-scale experiments fail to scale, i.e. become cheap enough and reliable enough to spread quickly around the world.

Advanced technologies require vast quantities of capital, expertise and energy to spread throughout the global economy. The necessary capital and resources are precisely what will be in short supply as demands on tax revenues and social safety nets skyrocket.

The Good News: We Have Agency In This Story

Despite these concerning global trends, health is determined at the individual level. Each one of us has the ability to improve our own personal health situation -- starting right now.

In Part 2: Putting Our Health Into Our Own Hands, we explore what we can do, as individuals and households, in response to the trends discussed above. As discussed in Chris' and Adam's recent book Prosper!, one of the most important components of true wealth is Living Capital -- the most essential component of which is our own bodies. Prioritizing our investments there gives us the best foundation upon which to pursue all of our other future goals.

32 Comments

As an emergency physician I watch in horror the mess that we have collectively gotten ourselves into with our poor health, complex and profoundly wasteful system, and hundreds of rules to ensure safety and reduce liability.

Some rambling anecdotes:

1. at least 50% of the people I see on a given shift are in the emergency department (ED) as a direct result of unhealthy and destructive life situations: Diabesity (diabetes, hypertension, arterial blockages in heart, brain and legs), smoking (chronic lung disease), alcoholism (vomiting blood, pancreatitis, liver disease, chronic brain deterioration), drugs (faking illness to obtain narcotics, withdrawal syndromes, overdoses and seeking admission to rehab).

2. much of disability in the elderly results from the combination of obesity with arthritis --and the resulting deconditioning. All obese inflamed people have pain (hip, back, knees), are short of breath with exercise, and begin to decondition to where climbing a few steps becomes very difficult. At some point, they must go into nursing homes as they cannot care for themselves and they are far to heavy for family to lift. This is not a disease but a downward functional spiral that many do not recognize until very advanced.

3. A special note must go to the Pickwickian hypoventilation syndrome in the morbidly obese: massive layers of fat lie across the chest wall and fill the abdominal cavity restricting breathing movement. The brain slowly adjusts to not being able to exhale CO2 adequately and the person moves into permanent respiratory failure, weakness, cognitive decline, exercise intolerance. I see this everyday I work.

4. The community's poor and uninsured use the ED for primary medical care. The ED is the only place where you can see a doctor without insurance or putting money down. Since many do not have cars, they come in by ambulance. Some are hypochondriacs, many not terribly bright and many very anxious. Others are just very unsophisticated and need "to be checked by a doctor" every time one of the kids vomits, skins a knee or comes into the proximity of a spider. Medical records show an ED visit for someone in the family every 2-3 weeks. They are seen in the highest tech setting possible for the most minor concerns. And time constraint limit patient education opportunities.

5. Depressed, obese, arthritic, unemployed, Mountain Dew and Marlboro consuming people have pain. Often lots of pain. In many locations. And narcotics improve that pain (temporarily) and offers a blessed and blissful (but temporary) relief from depression. Going to the ED to get narcotics is a ubiquitous pass time of the rural poor in Virginia. And of course you have to prepare a good story: "Well. (takes a deep breath) I was up on the roof when my horse kicked the ladder and the tree fell over towards my car which hit the side of the house knocking loose a shingle.....(etc) .... and it hurts REALLY bad." (If you don't believe me I can lie on the floor and scream a bit. Do I need to do that today?) About 15% of patients are probably lying about everything they say.

6. And then there are the RULES. Tens / hundreds of hospital policies and rules to ensure uniformity, reduce liability risk, and conform with government regulation. And the bureaucracy to oversee the application of the rules.

An elderly woman with mild dementia falls and breaks her shoulder Christmas Eve. She will need around the clock narcotics during the next week. But no pharmacies are open due to the holidays. The hospital does not have an "out patient pharmacy license" so cannot dispense pain pills to take home. Without pain medicine, she cannot be sent home. But we cannot admit her either as she does not meet Medicare criteria for admission. We will have to hold her in "observation" status, which is not covered by any insurance and will cost her family about $2,000 cash. But the ED is short staffed and very busy the nursing supervisor declares a "No ED Hold" condition (as is her prerogative to ensure good department flow) and the CDU (the observation unit) is closed down for the holiday. Thus she cannot be sent home, cannot be admitted to the inpatient floor, cannot be admitted to "obs" and cannot be held in the ED for the night. All for lack of $5 worth of pain pills.

7. Sometimes patients just don't go to work and are told that they "must get a doctors note." They come to the ED, tell a tall tale, have $1,000 -$2,000 worth of tests that are surprisingly normal, and are given an off work note.

A doctor I know who left medicine/research said patients would compete to achieve the highest Medicare bill. Another doctor I know was put in charge of a preventive medicine unit but the management would not allow him to implement preventive measures that reduced hospital use so he quit and opened a private non-insured practice (tests and drugs covered but not office visits).

Sand_puppy, thank you for reporting on the daily reality of our system. I honestly don't know how you and the other caregivers in the system can stand it. As I try to describe in my writing, it's not just the healthcare system that's dysfunctional and destructive--that is a symptom of a society that is dysfunctional and destructive, but is in massive denial. Sadly, humans habituate very quickly to corrosive conditions, and soon everyone thinks this destructive state is "normal."

Complexity is costly, and though I don't know how the current system's high complexity will transition to a much lower level of complexity, I think your report makes it clear that one way or another the system will become less complex.

Thanks Charles and sand_puppy, I agree with you both, and here's my 2 cents' worth. I am a family physician in Ontario, Canada with an absolutely conventional medical practice. I never discuss the three E's, "prepping" or related issues with my patients and I practice according to whatever guidelines are handed down by the Powers That Be. For me, it's just a daytime job. However, since 2008 I have seen the writing on the wall and in my spare time I am trying to put together a book, mainly intended for fellow healthcare professionals, about how one might design a post-peak healthcare system. You can find the work in progress at www.postpeakmedicine.com (free download).

There are three "clusters" of diseases which I see more of, day-to-day, than any others, and which form the bulk of my workload:

1. "Diabesity" - the constellation of conditions which include diabetes, obesity, hypertension, sleep apnea and osteoarthritis, as described above by sand_puppy

2. Low level mental health issues including anxiety, depression, insomnia, work related stress and chronic narcotic dependence (many of these often co-exist in the same patient)

3. Chronic pain. It's often difficult to differentiate genuine chronic pain from chronic narcotic dependence, and I suspect that again, they often co-exist in the same patient.

If I didn't have to deal with any of these issues, I would be working one day a week and doing something more useful with the rest of my time, like practicing a musical instrument, or gardening. I don't think I do much good for most of my patients because they never seem to improve. However, they look to me as being the provider of their health, it doesn't seem to occur to them to take control of their health themselves, so I don't give them a hard time - I just play the role society expects of me as best I can, and wait for what comes next.

In the event of the gasoline supply drying up, the banks closing or the grocery stores emptying, I don't think most of my patients would live very long.

Good luck, and if you get time, please give me some feedback on my book.

...since 2008 I have seen the writing on the wall and in my spare time I am trying to put together a book, mainly intended for fellow healthcare professionals, about how one might design a post-peak healthcare system. You can find the work in progress at www.postpeakmedicine.com (free download).

Outstanding book thus far, Peter. Well done!!! I'm on page 16 (Awareness and Denial). The book is very well written and chock full of succinct information about where we came from, where we're at, and where we're headed. You've clearly put a lot of intelligent effort into writing it. With your permission, I will share it with friends in the health care profession and also with the handful of brave students who will be taking one of two courses I'm teaching at the local university this spring (1. Understanding and Preparing for the Post Oil Economy [which closely follows The Crash Course videos] and 2. Depletion and Abundance [which relies on the new Prosper! book and puts personal and community preparation into high gear]).

Skipping ahead to the chapter on Shelf Life Extension Program (SLEP): My brother is a licensed pharmacist who reads a lot and keeps up with trends. He confirms that pharmaceuticals are often safe and effective long past the printed expiration date. I'll see if he has more specific information and references to contribute to that chapter.

Now, back to work for me. BAU for the rest of the day. (If I didn't own my company, I would fire my a** for today's obsessive surfing/researching about collapse. Argh!)

Sand_puppy - thank you for the excellent write up of some of your experiences in the system.

Peter thank you for confirming physician's experience, and for writing that book. I've just downloaded it but not yet read it. I'll be happy to provide feedback once I've gone through it.

Thumbs up to both of you!

It truly seems that unless one is willing to take control of and responsibility for one's own outcomes, then bad outcomes are the result.

It is a direct mechanism for health where people's poor dietary and lifestyle choices lead to 'diabesity' and all the metabolic disease issues that result.

But it goes well beyond that where we've ceded responsibility and control for a huge number of vitally important things including food, entertainment, security, and everything else vitally important but which can be co-opted and sold back to us.

It feels good to be among those who are actively resuming responsibility for ourselves, our loved ones and the future.

I was given the bum's rush from my last job. The Occ Health & Safety guy actually read the act and freaked out. His job attracted legal penalties if he failed. His response was to throw lots of paper at the monster. After all, his entire training was paper based. It was all he knew. He was the bureaucrat's bureaucrat.

I've had 42 Years experience as an Industrial Electrician. I know what is safe and what is not. I jumped up and down trying to get management to understand. What I got was Wilful Blindness. And a reputation as a trouble maker and not a team player.

The last I heard was that the entire electrical team was made to crawl on their bellies across a fragile roof 5 stories above the ground. Their paper-work was impeccable. Toe curling stuff.

Every bureaucrat needs to be exposed to Dr. IAIN McGilchrist again and again until they get it.

Thank you for the video link. It was first time exposed to many of those ideas.

Charles, Sand puppy and Peter, thank you for your excellent articles and the view from the trenches.

To me, it seems like the issues of diabesity and the ecosystem destruction are symptoms of the larger cultural. The idiolization of experts and the cognitive laziness that enables.

Nutrition is a great example of turning ones power over to others.

I have done yoga and martial art (judo, bjj, mma, arnis) for quite a while. I am getting to the point were it is all the same practice. Breathing, movement, body structure and internal and external energies. My yoga is jiujitsu without a partner and my jiujitsu is yoga with a partner.

But at the beginning... so many details, everything was fragmented. I am still learning that I am novice, bUT a different kind of novice. I feel the depth and intuition I am being blessed with applies to all, even if I don't understand why.

I think the experiences shared on this thread are so important and valuable, I'd like to incorporate them (leaving the sources anonymous) in an essay on my blog. I would not be quoting directly but drawing from the material. If anyone here would prefer not to have their comments used as source material, please let me know here or in a private message in PP.com (or email).

I am asking for permission because I think the cultural diseases (my term, not sure it's the best but it seems accurate to me) outlined here are so important. If we don't grasp the larger context of our healthcare crises, we can't really address the underlying causes.

Peter31, thank you for posting your book. I have downloaded the PDF and will read it in January. This information is of critical importance and when you're ready to distribute the book more widely, please let me know.

Just my own anecdotal evidence: I've never been more than a pound or two overweight (65.5", max weight ever, 152 lbs). Nonetheless, I seem to have diabetes symptoms: dark, thickened skin around the groin, foot fungus problems, some of the fatigue. My blood tests show that I have a low level of prediabetes.

I suspect NAFLD. As a result, I've carefully gone to a low-carb diet: mornings are eggs and coffee, lunch is raw vegetables and sometimes a skinless meat, dinner is as low-carb as I can manage. I still don't seem to be getting over it, but I've lost a pound a week down to 130. That's where I'm pretty much staying.

But I think something else is going on here. My wife has some similar symptoms, but also including high blood pressure. These symptoms started 5 or so years ago, at the same time as my wife lost a pre-born child to calcification of the placenta. We figured it was the CMV virus.

I still think so, but I've started to think that CMV may cause a lot of the diabetes around. It makes me wonder if gancycovir, or other CMV antivirals might battle diabetes. But it also makes me wonder if the epidemic of dibesity isn't actually an epidemic of disease.

CMV can infect virtually any organ of the human body. The most common organs include the blood, brain, colon, eye, heart, kidney, liver, lung and stomach. In the case of an organ transplant patient, the symptoms of CMV can be easily confused with rejection.

I came across your book online a couple of years ago now - and am heartened to see it has progressed somewhat, as I thought then - and still do now, it's a great topic to write about and discuss. Will definately download this most recent version for summer reading.

Taking control of your own health can be empowering, and frightening at the same time. We have been conditioned to think it's not within our abilities to do so - and encouraged to hand our mental and physical health over to 'experts' who may or may not care about the outcome, and are becoming increasingly stuck in dysfunctional systems, or marginalised by their peers for thinking/practicing out of the box.

Considering the access to information we now all have with the internet there is ample evidence available to almost all in the western world, about different conditions and treatment options (as well as prevention).

Going against the conventional advice for treating a condition twice recently taught me new things about how the body works, and to have renewed gratitude for what we have available to us right now. But it means you are questioning/defying the experts.

The first time I was trying to treat an inflamed, sore nail-bed without antibiotics, but it got to the point I couldn't perform my duties and could squeeze out pus so needed it fixed even though I am reluctant to use antibiotics. Visit to my GP for a script. Cost $20 AUD. Second time was for the thrush (sorry guys - too much info I know - but if you are medically inclined I'm sure you can cope with knowing and understand the agony) the antibiotics (and Christmas sugar pig-out) caused - with public holidays and shops closed I wanted treatment sooner rather than later, and cheaper if possible so dabbled with some effect in home remedies. I went to the pharmacist for that, who learned a little from me, and gave me some options because his non-western heritage enables him to think wholistically and he could see I was amenable to new ideas - rather than just wanting a magic tablet. Cost $50- AUD with some spare meds tucked away for a just in case in the future event.

Will I consult online references and my printed texts again - most definately (these are not the first times I have done my own research.) I am lucky to have access to this information and to western medicine options if needed. BUT I feel unlucky that a lot of knowledge that may not be profitable to industry is slipping away from us as a generation of wise older people pass on.

Sorry for the long post but health and nutrition (and plants and gardening) are something that interest me a lot, and I could go on all day. Studying Nursing at the moment but really have a hard time on placements helping people with diseases of sloth and ignorance, and working in germy hospitals/institutions. Would like to learn more about natural medicine but in my part of the world it is a lot less accepted and a more impoverishing career choice. I currently work in community/disability care and hope I can wrangle a community based nursing position when the time comes. Lots of opportunity to educate clients in their own environment and create empowerment.

The Federal Government Admitted Cannabis May Help Fight Brain Cancer: Though the government has long known about the medical benefits of cannabis — it holds patents on several medicinal qualities — the National Institute on Drug Abuse made waves this year when it published a document acknowledging the healing properties of cannabidiol, a non-psychoactive endocannabinoid. In particular, it noted “[e]vidence from one animal study suggests that extracts from whole-plant marijuana can shrink one of the most serious types of brain tumors.” Though more research is needed, the government’s admission was unexpected, albeit welcomed by many cannabis enthusiasts. Other studies this year suggested cannabis may help heal broken bones and is associated with lower rates of obesity.

Aloha! To me the most radical gangsta that ever lived was Gandhi! He overthrew an Empire by saying one word ... NO!! NO we will not participate in your Empire! The British were completely without defense. If enough people can say NO they can make changes without the authority of Congress or without Mr Hope & Change himself! We have these Gandhi's in our midst.

I first met Ron back a few years at our LA studio where I am a development partner. He came in and told us about his GANGSTA DEAL in South LA. He essentially pulled a Gandhi and told the City of South Los Angeles .. NO!! NO you cannot kill our kids! NO you cannot sit idly by and do nothing and NO you cannot let my people be your victims of state corruption!

If you go HERE you'll see the real cure for all our state sponsored ills and you will see them put into practice by one man. We need to say NO! We need to take back our country from these career parasites called politicians and let them be the victims of their own hubris! Abandon their Debt Empire like Gandhi did the British!

Why should any citizen with self respect think that trashy vacant lots, liquor stores and dialysis on every corner is acceptable as the "norm"? When these "hoods" exist it is testament to failed government and corrupt politicians.

The perfect storm of food health energy and economic collapse is brewing. Read the prologue in the book the synth The Synth for a great summary of the coming future. Percy nails it... Great story too, there are thinkers around obviously.

Its looking like a future of reduced life expectancy, war and famine until we can figure out how to escape this rock. Anyone with their eyes open, who understands that humans on Earth are just like chimpanzees at the zoo (very little higher brain function) knows that there is no hope for the collective. There's only the possibility of pockets of harmony for those who can insulate themselves from the mayhem.

Chris Martenson wrote: "unless one is willing to take control of and responsibility for one's own outcomes, then bad outcomes are the result. It is a direct mechanism for health where people's poor dietary and lifestyle choices lead to 'diabesity' and all the metabolic disease issues that result."

Personal choices are always SOME part of the picture, but it is as yet unclear the extent to which diet and lifestyle choices are responsible for obesity, metabolic syndrome and diabetes. We are living in an obesogenic and diabetogenic environment, created (apparently, as far as we know so far) by industrial development. Much if not most of the burden of these diseases is caused not by lifestyle choices, but by environmental factors that are essentially unavoidable at this time. The environmental factors are unmasking genetic or constitutional tendencies.

People are generally much healthier, living longer lives, than at any point in history, but the industrial modernity that made that health and longevity possible also has side effects, evident in the statistics on obesity and metabolic diseases. It is a big mixed bag.

"Things are getting better and better, and worse and worse, faster and faster" -- Tom Atlee

Thanks for your contribution Alan. I thought you and other readers might be interested to compare and contrast the psychological responses to overweight and obesity from two different patients (I'm a family physician).

The first patient is me. I'm 56 and all my life I've never had a problem with weight, despite a diet containing unwise amounts of chocolate and fast food - until now. In the last three years, I've gained 15 pounds, and although technically I'm not overweight (BMI 23.2) I have gone from the slim end of normal to the heavy end of normal, I don't like the way this looks and feels, and I know that I have to nip this in the bud before I slide into overweight and obesity. So I'm cutting out most of the junk apart from occasional treats, taking more exercise and spending less time sitting in front of my computer. I would call this a "rational" response: I have identified that there is a problem, owned up to being the cause of the problem, and devised a plan for dealing with it.

The second patient is a typical example of the many patients I see in my office every day who are overweight or obese. There is some individual variation of course, but the most common response is as follows:

When I mention the fact that they are overweight or obese, no matter how tactfully, their initial response is surprise. They were apparently not aware of it before I mentioned it. Then immediately after the surprise comes denial: they have big bones, all their family have always had big bones, it's not fat but retained fluid, they always put on weight over Christmas / during the summer BBQ season and they always lose it once Christmas / BBQ season is over, etc. Then they list all the foods which they DON'T eat, which can take about five minutes because there seems to be an almost infinite number of potentially unhealthy foods which can't possibly apply to them because they never eat them. And so on it goes.

For about my first five years of family medical practice, I felt I was duty bound to have this conversation with my overweight and obese patients, and I dutifully recorded it in their medical chart. First I would record what they said, but after a while I got tired of that because it was taking too long, so I just wrote "usual conversation". That will probably puzzle some future medical researcher or litigation attorney who reads my charts and wonders "what does THAT mean?"; well, that's what it means.

Then after about five years I just gave up and stopped mentioning overweight and obesity to patients, because really, what was the point? If Reality is screaming in their ear and stomping on their toes trying to get them to take notice of the fact that they are overweight or obese, but they are not listening to Reality, then they are not going to listen to me. So this second response is what I would call an "emotional" response, rather than a rational response, and it's by far the most common response.

I too was at the high end of healthy: 65",150-152 lbs. When I found my LDL going up (120), and my blood glucose hit 5.8 A1c, it was time to respond... especially since for five years I had skin symptoms of diabetes.

Why would I respond like a diabetic to nondiabetic symptoms? I don't know, but -- get this -- IT DOESN'T MATTER. I do. So I went on a 1-lb a week weight loss low-carb diet: mornings, coffee and maybe McDonalds eggs; afternoon, raw veggies and lean meat/tuna, evening, try not to go crazy.

After four months of that I'm down around 130, and targeting 124: sometimes I missed my goals.

And my diabetic-like symptoms only increased, though it may have been virus symptoms instead. So, being unsure, I went ahead and got BG test kits, and an A1c test kit. So far, it indicates no problem: A1c at 5.6, fasting BG at 89, post meal BG at 1 hr=92 for a lean meal, 115 for a higher-end-carb meal.

So who knows. In the end, I can try to be rational, but my body's gonna do what it's gonna do.

Regarding you personally: at a BMI of ~23, it seems that you have nothing to worry about, unless your weight gains are continuing with no sign of stopping. There's evidence now that somewhat higher bodyweights, in the "overweight" range, may reduce risk and be protective against a variety of diseases. The evidence is not clear-cut, and it does not mean that higher weights do not also predispose to other diseases, but it would appear to be a wash, at worst. If I were you I would not worry about your slight weight gain.

Regarding your patients: respectfully I would like to suggest that you focus on their health, and not on their weight. The two have a tangential, unclear relationship, which is another way of saying they are largely incommensurable. For the most part, with the exception of morbid obesity -- starting at BMI ~35-40 -- we are safe in simply ignoring bodyweight and focusing exclusively on known risk factors and warning markers, and on non-controversial health behaviors. Risk factors/markers would include the usual: lipids, cholesterol, BP, fasting BG, insulin resistance, inflammatory markers, and so on. Non-controversial health behaviors would include regular aerobic exercise (with some weight training to boot, if they are up to it), tons of fruits and vegetables, reduced refined foods (extrinsic sugars and fats), and so on.

Bodyweight, and BMI, have always been lousy indicators. They often mean nothing at all more than what they literally, directly mean; e.g. if your BMI is 23.2, that means that your BMI is 23.2. Period. Nothing further can be inferred. They DO mean something more than that at the extremes: both very high and very low BMIs are inconsistent with health, usually, but even then there are exceptions. Rather than weight or BMI, other anthopometrics such as waist circumference or, still better, waist:hip ratio, have much better correlation with metabolic health or ill-health. It is possible to carry large amounts of weight about the buttocks, hips and legs -- typical female pattern -- without any metabolic compromise at all. Abdominal adiposity is the problem, and it can exist without weight or BMI issues. It is quite possible to be a "fat skinny person": normal BMI, and thin in appearance, with high percent bodyfat and loads of intra-abdominal fat that associates with high risk.

Take a close look at the HAES movement: Health At Any Size. The idea is that it is possible to be healthy -- have really good numbers on all the usual risk markers, have excellent cardiovascular fitness, etc. -- while also having a high bodyweight or BMI. There is increasing hard evidence for this proposition. Among other things, it has been shown that people with even quite high BMIs (supposedly "dangerously high") can achieve excellent condition by embarking on programs of regular exercise and dietary improvement, losing only modest or insignificant amounts of weight -- say, ~5% of their starting weight. In other words, please let us forget about bodyweight, throw away the damned scale, and focus on HEALTH. Please. Pretty-please. :-)

A fascinating debate Alan, and thank you once again for your contribution! I wasn't aware of the HAES movement, but I have read its description on Wikipedia carefully, and these are my observations. They are based mainly on what I see in everyday practice in my office rather than academic research. I'm not downplaying the importance of research, because it plays an important role in challenging our assumptions, but it can sometimes also lead us astray because it can sometimes be subject to biases of its own.

Most of the diabetics I see in my office have abdominal obesity. I see the occasional thin diabetic, but they are rare, and most of them are Type 1 diabetics which as you know become diabetic via a completely different mechanism than the far more common Type 2 diabetics. Being a diabetic seems to me to lower your quality of life considerably: who would want to pop pills or take injections every day and go and see the doctor every three months for a checkup? OK, maybe some people would like that, but I wouldn't. So my personal observation would suggest a link between abdominal obesity and diabetes, which would be a good reason to avoid abdominal obesity.

I am somewhat doubtful about the claim that you can have a high BMI but still be healthy, because I have literally never seen it in my office. I known that theoretically you could have, say, a bodybuilder with a lot of muscle mass in his or her upper body, a slender waist, a high BMI, and perfect health, but I have never seen one of these people walk into my office. It's possible that this may be a selection bias, and that those people are out there in the community but they are so healthy that they never go to the doctor. It's also possible that Yetis, unicorns and the Loch Ness Monster are also out there in the community, even though I have never seen any of them either. So let's just say I'm open minded about it but sceptical.

An alternative explanation for the "I have a high BMI but I am healthy" argument, is that the high BMI person would like to believe that this is true and is deceiving him or herself. And I think I am on stronger ground here because I see this a lot in obese people. I gave a few common examples earlier: "I have big bones" (a common British one; I don't hear it so often in Canada), "I always gain weight in BBQ season but lose it afterwards" (that one is very Canadian), "I hardly eat anything" (very common in both countries) and so on. In fact, I believe there is research which shows that if you ask an obese person to keep a food diary of what they say they eat, then you confine them in a hospital and give them exactly what is in the diary, they lose weight, suggesting that their recollection of what they are eating is not accurate.

A further confirmation of this is the success of bariatric surgery in making people lose weight. If a morbidly obese person has their stomach reduced in size or bypassed, they lose weight rapidly. I have seen this in my own patients many times: it has an almost 100% success rate. However, if you think about it, this is just a form of surgical behavior modification. The patient could achieve the same result without surgery just by eating less; however, it seems that they find this impossible to do. And usually, these are the same patients who say before their surgery "I hardly eat anything".

So, going on to the HAES movement, Wikipedia says that this is a "political movement" and that "HAES ideas have recently gained popularity among proponents of the fat acceptance movement as an alternative to weight loss". If this is true, this for me sets alarm bells ringing, because it sounds suspiciously like another variation of the above "wishful thinking" ideas: the obese person finds it hard to lose weight, so gives up trying to lose weight and justifies this to him or herself by saying it's OK to be obese.

The Wikipedia article about HAES also puts forward the view that it is better to prevent obesity, or lose weight soon after gaining it, than to allow the weight gain to progress to obesity and then try to lose it, which after many years of being obese may be virtually impossible without surgery. I think that's sensible advice. That's why I'm concerned about my own weight gain (15 pounds in 3 years) because I can see that I am starting on the same trajectory as my obese and morbidly obese patients, and I don't want to follow in their footsteps.

Peter:
"my personal observation would suggest a link between abdominal obesity and diabetes"

No question about it. Abdominal adiposity is without doubt a risk factor for metabolic syndrome and type 2 DM. Abdominal adiposity is much worse than adiposity elsewhere. In fact, there is evidence for protective effects of adiposity elsewhere. It is the stomach fat that is the killer. That's why I suggested (following the advice of prominent researchers) using waist circumference or waist:hip ratio as much better target numbers than weight or BMI. The former are REAL risk factors; the latter are not, or not much, except at the extremes (BMI upwards of ~35).

"I am somewhat doubtful about the claim that you can have a high BMI but still be healthy, because I have literally never seen it in my office."

I believe it, and the likely reason is that they've never tried. It takes real WORK to get healthy, and the typical overweight person may not have ever undertaken that work. But it is quite possible to get healthy while still heavy, and it has been demonstrated repeatedly in the literature. Some weight might be lost, incidentally, in the course of getting healthy, but the main focus is getting healthy, not weight loss. Let the scale do whatever it is going to do that is consistent with health. More vegetables, more exercise, less refined food, less animal products, more fiber, optimal sleep, magnesium supplements, less TV, etc., etc.

"let's just say I'm open minded about it but sceptical."

As you should be.

"An alternative explanation for the 'I have a high BMI but I am healthy' argument, is that the high BMI person would like to believe that this is true and is deceiving him or herself."

I am certain that this happens a lot, and it is the danger of the HAES concept. But let's not overstate it. The HAES concept -- the idea that one CAN be both heavy and healthy -- does not suggest that every overweight person IS healthy. Health is determined, insofar as we can determine it, by a number of measures. If those measures are out of line, then you are unhealthy or you are at risk of disastrous health outcomes.

"If a morbidly obese person has their stomach reduced in size or bypassed, they lose weight rapidly."

Yes, of course. No one denies this. The question is: what is the health benefit? Always keep in mind that health cannot be cleanly inferred from weight. Some of the literature on bariatric surgery reports rather shocking loss of lean mass along with fat mass; hence "weight" is lost, including a great deal of muscle, vital organ and other functional tissue. Just how healthy are you going to be after that? I don't know. I suppose it might vary by case.

Bariatric surgery might be very useful for selected morbidly obese cases. What I object to is the assumption that "they lost a ton of weight, therefore they must now be healthy". Not so.

I am in favor of whatever improves people's health. If gastric bypass improves health, then I am for it. Does it? Maybe it does. But let's keep in mind that it is a very radical, risky and expensive way to improve health, if it does improve health.

"... this for me sets alarm bells ringing, because it sounds suspiciously like another variation of the above "wishful thinking" ideas: the obese person finds it hard to lose weight, so gives up trying to lose weight and justifies this to him or herself by saying it's OK to be obese."

Please turn off the alarm bells. Yes, it might be OK for them to be obese. That's the point. Why not build health first, and find out? It might be OK, and it might not be OK, but why not work on building health as the first goal? That is your role as a physician, after all: to treat people's states of ill-health, and help people become healthy, not to treat abstract numbers. Weight and BMI correlate only poorly with health. Other numbers correlate much more strongly -- so let's treat THEM.

This is, I believe, the appropriate approach to the patient: "let's work on your health first, and then see if you need to lose additional weight or not". Maybe they will need to restrict calories and lose some more weight; maybe they won't. We don't know until we try. But we do know from the literature that huge health improvements are quite possible with minimal weight change.

I agree that the HAES movement -- the political movement -- goes too far in some respects. It overlaps with the "fat acceptance" movement, which is a valid civil rights movement, opposed to discrimination and bigotry which are rampant. It is important to embrace the civil rights aspect while at the same time attending to the real medical/biological issues.

Personal aside: I was obese, technically, for at least 10 years, but I have great numbers: BG, BP, lipids, all of it. Actually, a few of my numbers were slightly off, years back, but I corrected them, while still at a BMI of ~30 ("obese"). I eat a great diet. I train hard, often. I take megavitamins and many supplements. I am in great shape. Just recently I dropped some pounds and am at ~28, so now I am just "overweight", not "obese". But who gives a damn about my BMI or weight? Does it matter? NO! It does not matter. It has zero medical significance. I seek to improve my health and appearance, and weight and BMI are largely irrelevant to those goals. I want to gain 10-20 pounds of muscle, and I have a plan to do so. No doubt I will lose some fat in the process, so my weight and BMI will likely remain about the same. Still "overweight". Big deal. Who cares?

I really dislike the term abdominal obesity, because it lumps three types of possible fat together, which have far different consequences: liver (organ) fat, muscular fat, and skin fat.

As far as I can tell, muscular fat is the least damaging to a person's overall health: it's the marbling fat in your steak. However, when you do lose weight, there is a severe possibility that the loss of this fat can help cause a hernia, which happened to my father. The treatment of that then later triggered a stroke. So that then means that if you have significant weight loss, you should be really careful of your abdominal wall, and work on rebuilding the muscles as if you WERE damaged there.

The second type of fat is skin fat. This is the cover fat around the steak. If you have to eat grade D meat, do NOT eat the cover fat, because it's going to be packed with toxic steroids, antibiotics, or other poisons (I say this from my brother's experience of an unintended steroid rage that luckily had no consequences). This skin fat around the stomach is dangerous to a person's health, but not the most dangerous. Moreover, when you lose this weight by dieting, there is the probability that toxins you had in your system when you put the weight on, may re-enter the body... because this is where the body sticks bad stuff. So while you lose weight, you should watch out for previous problems.

The worst is liver fat. I think that contributes more to diabetes than anything; and this is where you want to look up "fatty liver disease", "non-alcoholic fatty liver disease", and how NOT to lose weight (because losing weight too rapidly can be a REALLY bad thing).

The liver is not a typical fat storage organ such as the area under the skin (subcutaneous fat). Non alcoholic fatty liver disease has been associated with obesity, but it is a metabolic disorder, not a common consequence of weight gain.

A metabolically active, 'bad' fat storage site is the area inside the abdomen, under the abdominal muscles. The omentum is a fan of fascia and fat that partially surrounds our abdominal organs. This is a common fat storage site, and high amounts of omental fat have been associated with metabolic disorders and chronic inflammation.

I am not anything close to a doctor. You point out yet another type of abdominal obesity that I *was* aware of, but had forgotten... and which is also extremely damaging to the health. So there are actually at least four kinds of abdominal obesity, one of which is metabolic/rare/related to my own problem.

As such, my general point still stands: that "abdominal obesity" is so generic as to make it useless in either diagnosis, or proper weight loss. When you separate them out, then it would help a person deal with things, because they have something to deal with.

Let me offer a suggestion to the doctor, for something instead of "had the usual discussion". The "usual discussion" doesn't work, because it has no impetus, nor means to an end.

Suppose, that our doctor went and hired the services of a dietician (did I spell that correctly?) with a focus on assisting weight loss. Then, he identified *which* type of obesity was involved for a patient. Once that was the case, any of his patients could come in, plunk $10 down on the checkin-clerk's desk, and pose a question. The question would be forwarded with the patient's file to the dietician, and a right answer would come back within a week, the generic answer be posted in a book (available for free), and be emailed to the patient.

So then... there's a collection of advice generics, but also access to specific answers when needed.

Then... we still need impetus. I'm going to posit that impetus isn't "I'd like to be healthier", but "I hate those migraine headaches". I'm also going to posit that most of those overweight people get headaches that seem like migraines, but actually are hypostatic headaches caused by carb overload. So instead of saying "you need to lose weight", say "Let's talk about headaches." (What?!?) "You get migraines, don't you?" (Yes... I hate em. Tylenol only helps a little.). "So, I don't think they're migraines. I think they're from carb overload. So I'd like you to try something". Then suggest a limited carb diet: try it for two weeks, and then pick a day when a headache the following day won't impact the daily schedule, and HIT a high carb day, watch what happens.

NOW you have impetus. The person would like to be healthier, but BOY THEY HATE THOSE HEADACHES.

"I really dislike the term abdominal obesity, because it lumps three types of possible fat together, which have far different consequences: liver (organ) fat, muscular fat, and skin fat."

For the record, it is abdominal *adiposity*, not obesity. But I agree, it is an imperfect term. It needs to be seen in context, however. It is much, MUCH better than the naked term "obesity". When you specify the abdomen, suddenly you are far closer to the real problem, and you've departed from the areas in which adiposity is not only not harmful, but potentially protective. As I pointed out above. non-abdominal adiposity is by some measures protective against disease. A woman with heavy hips, legs and butt is probably OK, provided she does not have "apple" (abdominal, male pattern distribution) fat. It is abdominal fat that is the real culprit. So, IOW, let's not let the perfect be the enemy of the good. Abdominal adiposity should be our focus, for now. Later, perhaps, when MRI or equivalent technology -- capable of precisely quantifying precise local deposits -- has fallen in cost to such an extent that it can be a routine office-visit check, then we can be more specific. For now, simple waist circumference is a huge improvement over BMI or bodyweight.

"my general point still stands: that "abdominal obesity" is so generic as to make it useless in either diagnosis, or proper weight loss."

I disagree. It is a huge improvement over BMI/weight. It is the latter (BMI) that is "so generic as to make it (almost) useless". Modest reductions in waist circumference -- barely enough to register as significant weight loss at all -- can produce big metabolic improvements, which reflects the point on the table: that abdominal fat is the real culprit.

By the way, I am talking in population terms, i.e. what is true across populations. What I say will not hold true for every individual. You might be an exception. But it will hold true in general, across a population.

Everyone ...its high time now..!! We humans need to understand that the high population, pollution, cutting down trees is harming our planet earth now. Earth is slowly turning into a planet that is unfavorable for life to exists. People have become selfish and not thinking about our future generations. We are making it difficult for them to live. And, we are complaining now of deaths due to pollution, whereas we are the ones responsible for all.